pleural diseases

PLEURAL DISEASES
By:
SETIA PUTRA TARIGAN
Pulmonary Department, Faculty of Medicine,
Sumatera Utara University/ Adam Malik Hospital
Medan
2008
ANATOMY OF THE PLEURA
I. Pleura is the serous membrane:
1. Visceral pleura: covers the lung parenchyma, until
interlobar fissures
2. Parietal pleura: covers the mediastinum,
diaphragm and the rib cage.
The space between the two layers of pleura call as
pleural space.
II. Pleural space contain a film of fluid: pleural fluid, as
lubricant and allows the sliding between the two pleuras
during respiratory movements.
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ANATOMY OF THE PLEURA
(contd)
III. Histology: covered by a single layer of
mesothelial cells. Within the pleura are blood
vessels, mainly capillaries, lymphatic lacunas
(only in the parietal pleura), and connective
tissue.
Two important function of the connective
tissue in the visceral pleura:
- contributes to the elastic recoil of the lung
- restricts the volume to which the lung can
be inflated
ANATOMY OF THE PLEURA
(contd)
Elastic and collagen fibers are
interdependent elements.
The mesothelial cells are active cells,
sensitive and responsive to various stimuli
and very fragile. They may be
transformed into macrophage.
Scanning electron microscopy: microvilli
are present diffusely over the pleural
surface:
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ANATOMY OF THE PLEURA
(contd)
IV. Pleural fluid: the important in the understanding
are volume, thickness, cellular components, and
physicochemical factors.
Normally a small amount of pleural fluid present,
behaves as a continuous system.
The total white cell count of 1,500/mm3,
with 70% monocytes. The protein, ionic
concentrations are differ significantly from serum.
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ANATOMY OF THE PLEURA
(contd)
V. Blood supply: from the systemic capillaries
VI. Lymphatics:
Lymphatics: the lymphatic vessels in the parietal
pleura are in communication with the pleural
space by stomas.
VII. Innervation:
Innervation: sensory nerve endings are present
in the costal and diaphragmatic parietal pleura.
The visceral pleura contains no pain fibers.
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PHYSIOLOGY OF THE PLEURAL SPACE
I.
The pleural space is important in the
cardiopulmonary physiology, as a buffer zone for over
loading of fluid in the circulatory system of the lung.
The gradient of pressure depend on the three
components:
- cardiac rhythm
- respiratory rhythm
- elastic recoil of the lung
“ PLEURODYNAMIC”: the capacity of the
pleural space to change in the pleural pressure
variability.
The normal pleural pressure ranged from - 8,1 to
-11,2 cmH2O (the negative or sub atmospheric
pressure).
Intrapleural pressure
Negative / sub atmospheric pressure
- 8,1 Cm H2O
inspiration
0 Cm H2O
-11,2 Cm H2O
expiration
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PHYSIOLOGY OF THE PLEURAL SPACE
(contd)
The pleural pressure changes associated with many
pleural diseases. Commonly by the increasing of
pleural pressure.
Pleural fluid formation from:
- pleural capillaries
- interstitial spaces of the lung
- intrathoracic lymphatic
- intrathoracic blood vessels
- peritoneal cavity
PHYSIOLOGY OF THE PLEURAL SPACE
(contd)
Pleural fluid absorption:
- Lymphatic clearance: fluid clearance through
the pleural lymphatics is though to explain the
lack of fluid accumulation normally.
Stomas in the parietal pleura, as an initial
drainage. There are no stomas in the visceral
pleura.
- Capillaries clearance: few for small molecules and
water across both pleural surfaces.
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CLINICAL MANIFESTATIONS
I.
Symptoms: mainly dictated by underlying process,
may have no symptom to severe illness.
- pleuritic chest pain
- dullness
- non productive cough
- dyspnea
II.
Physical examination:
- inspection: sizes of the hemithoraces and the
intercostal space
- palpation
- percussion
- auscultation: decreased or absent breath sounds,
pleural rubs
LABORATORY APPROACH
Separation of exudates from transudates
Appearance of pleural fluid
Bronchoscopy
Thoracoscopy
Needle biopsy of the pleura
Open pleural biopsy
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PLEURAL DISEASES
Pleural effusion
Pneumothorax
Empyema
Hydropneumothorax
Pyopneumothorax
Hemothorax
Chylothorax
Mesothelioma
Etc
PLEURAL EFFUSION
Definition: an accumulation of pleural fluid
in the pleural space.
Pathogenesis:
= Increased pleural fluid formation
= Decreased pleural fluid absorption
= Both increased formation and decreased
absorption
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PLEURAL EFFUSION (contd)
Increased pleural fluid formation:
- increased interstitial fluid in the lung
- increased intravascular pressure in pleura
- increased permeability of the capillaries in
the pleura
- decreased pleural pressure
- increased fluid in the peritoneal cavity
- disruption of the thoracic duct
- disruption of the blood vessel in the thorax
PLEURAL EFFUSION (contd)
Decreased pleural fluid absorption:
- obstruction of the lymphatics draining
- elevation of systemic vascular pressure
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PLEURAL EFFUSION (contd)
Clinical manifestations:
= Symptoms: mainly dictated by the underlying
process; no symptom, pleuritic chest pain,
referred pain, dullness, dry/ non productive
cough, and dyspnea.
= Physical examination: change in sizes of
hemithoraces and intercostal spaces. Tactile
fremitus is absent or attenuated, dull in
percussion, decreased or absent breath sounds,
pleural rub during the latter of inspiration and
early expiration (to and fro pattern)
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PLEURAL EFFUSION (contd)
Separation of transudative or exudative effusion:
Light`s criteria for exudative pleural effusion, one
of:
= pleural fluid protein divided by serum protein
greater than 0,5
= pleural fluid LDH divided by serum LDH
greater than 0,6
= pleural fluid LDH greater than two thirds of
the upper limit
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PLEURAL EFFUSION (contd)
exudative
Tuberculosis
Tumor
Pneumonia
Trauma
Collagen disease
Asbestosis
Uremia
Radiation
Sarcoidosis
Emboli
transudative
Congestive heart
Nephrotic syndrome
Cirrhosis hepatis
Meig’s syndrome
Hydronephrosis
Peritoneal dialysis
TRANSUDATIVE PLEURAL EFFUSION
Occurs when the systemic factors influencing the
formation and absorption of pleural fluids are
Altered.
The most common cause: congestive heart
failure (CHF);
Pathogenesis: pressure in the pulmonary capillary
Elevated
fluid enter the interstitial spaces of
the lung
across the visceral pleura into the
pleural space.
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TRANSUDATIVE PLEURAL EFFUSION
(contd)
Clinical manifestation: associated with
CHF:
- dyspnea on excertion
- peripheral edema
- orthopnea or paroxysmal nocturnal
dyspnea
- distended neck vein
- rales
- gallop
- signs of the pleural effusion
TRANSUDATIVE PLEURAL EFFUSION
(contd)
Treatment:
- digitalis
- diuretics
- afterload reduction
- thoracocentesis
- pleuroperitoneal shunt
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TUBERCULOUS PLEURAL EFFUSION
Pathogenesis:
- sequel to a primary tuberculous infection
(post primary infection)
- reactivation
- result from rupture of subpleural caseous
focus in the lung
- delayed hypersensitivity
TUBERCULOUS PLEURAL EFFUSION
(contd)
Clinical manifestation:
- most common as an acute illness: < 1
week
- cough, usually nonproductive
- chest pain, ussually pleuritic
- fever
- younger than patients with parenchymal
tb
- usually unilateral and can be of any size
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TUBERCULOUS PLEURAL EFFUSION
(contd)
Diagnosis:
- acid fast bacilli of: sputum, pleural fluid
pleural biopsy specimen
- granulomas in the pleura (on
thoracoscopy)
- elevated of ADA (adenosine deaminase)
- 20% with parenchymal infiltrate
- 39% with hilar adenopathy
- tuberculin skin test
TUBERCULOUS PLEURAL EFFUSION
(contd)
Treatment:
- Chemotherapy
- Corticosteroid
- Thoracocentesis
- WSD
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PNEUMOTHORAX
DEFINITION: air in the pleural space.
CLASIFICATION:
1.
Spontaneous pneumothorax
occur without antecedent trauma or other obvious cause,
devided into:
•
•
Primary spontaneous pneumothorax (PSP):
(PSP): occur in
healthy individuals
Secondary spontaneous Pneumothorax (SSP): occur as a
complication of underlying lung disease, most commonly
COPD (chronic obstructive pulmonary disease).
PNEUMOTHORAX
2. Traumatic pneumothorax:
occur as a result of direct or indirect trauma to
the chest:
3. Iatrogenic pneumothorax: occur as a an
intended or inadvertent consequence of a
diagnostic or therapeutic maneuver.
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PRIMARY SPONTANEOUS PNEUMOTHORAX
(PSP)
INCIDENCE
Males: 7,4/100.000 per year
Females: 1,2/100.000 per year
Relative risk in smoker 77-102 times higher
Usually taller and thinner, associate with genetical
predisposed to bleb formation
Peak age of the occurrence is in the early 20s
Rare after age 40
PRIMARY SPONTANEOUS PNEUMOTHORAX
PATHOPHYSIOLOGY
The negative/ sub atmospheric
pressure of the pleural space and
The positive pressure of the alveolar
pressure always positive
Develop of communication between
alveolus and pleural space
Air flow from alveolus into pleural
space
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PRIMARY SPONTANEOUS PNEUMOTHORAX
CLINICAL MANIFESTATION
The main symptom: chest pain and dyspnea
Usually develop at rest
PD: moderate tachycardia. If HR > 140 or if
hypotension, cyanosis is present, a tension
pneumothorax should be suspected
Larger of the chest, move less, absent of
fremitus tactile, hyper resonant in percussion
note and reduced or absent the breath sound
on the affected side.
The trachea may be sifted toward the contra
lateral side
PRIMARY SPONTANEOUS PNEUMOTHORAX
DIAGNOSIS:
= Clinical history
= Physical diagnostic
= Chest xx-ray: is a definitive diagnostic,
showed the visceral pleural line. Expiratory
films are more sensitive than are inspiratory
films.
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QUANTITATION:
PRIMARY SPONTANEOUS PNEUMOTHORAX
RECURENCE RATE:
= Without thoracotomy: 52%, 62% and 83% in
patient had first, second and third
pneumothoraces respectively
= Chest CT may predict the recurrence, where
the individual with numerous and the largest
bullae would be most likely had recurrence
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TREATMENT
A. Observation
Resorbed of the air in the pleural space about
1,25% per day, if the communication between
the alveoli and pleural space is eliminate
= Bed rest
=
B. Supplemental Oxygen
= Supplemental oxygen: increased the rate of air
absorption until 6 time
= As a routine treatment for all type of
pneumothorax
TREATMENT
C. Aspiration
= As a initial treatment for psp > 15%
= By GG-16 needle with internal
polyethylene catheter, inserted into
anterior 2nd ICS at mid clavicle line after
local anesthesia, a three way stopcock
and 60ml syringe
= 64% successful
= Tube thoracostomy for unexpanded lung
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TREATMENT
D. Tube thoracostomy
= Permits the air to be evacuated effectively
and rapidly
= Connected to underwater seal, low
pressure continuous suction (up to
100cmH2O), or to a Heimlich valve
E. Pleurodesis
= Instilation of any sclerosing agent to the pleural
space or by abrasion to create obliteration of the
pleural space
TREATMENT
F. Thoracoscopy
= Direct view to the entire thoracic cavity
= To treat the bullous disease responsible
for the pneumothorax
= To create a pleurodesis
G. Thoracotomy
= For patient who fail to previous
treatment
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SECONDARY SPONTANEOUS
PNEUMOTHORAX (SSP)
SSP are more serious than PSP, because
decreased the lung function of patient withy
already compromised lung function
INCIDENS: 6,3/100.000/year (US)
ETIOLOGIC FACTORS:
= COPD
= TB
= Asthma
= Pneumonia
= Lung cancer
SECONDARY SPONTANEOUS
PNEUMOTHORAX
CLINICAL MANIFESTATIONS:
= More severe than PSP
= Mostly: dyspnea, chest pain, cyanosis,
and hypotension
= Mortality: 16%, is associated with
respiratory failure
= Recurrent rate: 44%
= PD: similar to PSP, but less helpful,
especially for patient with COPD
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SECONDARY SPONTANEOUS
PNEUMOTHORAX
DIAGNOSIS: established by chest xx-ray, show of a
visceral pleural line. Must differentiation from
large bulla, if any doubt, CT thorax may be done.
TREATMENT:
The goals are to rid the pleural space of air
and to decreased a recurrence; treatment are
the same as PSP, except the aspiration is a limited
role in SSP.
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MADE IN ENGLAND
PUMP
CC
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SAFETY TUBE
WSC
PCC
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PUMP
25
CC
WSC
PCC
MADE IN INDONESIA
PUMP
CC
25
WSC
PCC
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PUMP
25
CC
WSC
PCC
MADE IN INDONESIA
PUMP
50
CC
SAFETY TUBE
WSC
PCC
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EMPYEMA
DEFINITION:
Is pus in the pleural space or pleural effusion with thick,
purulent appearing pleural fluid.
State precipitating empyema:
- Pulmonary infection
- Surgical procedures
- Trauma
- Esophageal perforation
- Spontaneous pneumothorax
- Thoracocentesis
- Subdiaphragmatic infection
- Etc
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EMPYEMA (contd)
The evolution of empyema can be devided into 3
stages:
1. Exudative stage: rapid outpouring of sterile
pleural fluid into pleural space
2. Fibropurulent stage: bacteria invaded the
pleural fluid, formation of fibrin, membrane
and tendency toward loculation.
3. Organization stage: fibrobalsts grow and
produced an inelastic membrane as called the
pleural peel.
EMPYEMA (contd)
BACTERIOLOGIC FEATURES:
- Streptococcus pneumoniae
- Staphylococcus aureus
- Mycobacterium tuberculosa
- Escherichia coli
- Klebsiella species
- Proteus species
- Pseudomonas species
- Bacterioides species
- Peptostreptococcus species
- Etc
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EMPYEMA (contd)
CLINICAL MANIFESTATIONS
- No different from bacterial pneumonia:
acute febrile illness, chest pain, sputum
production and leukocytosis.
- In anaerobic bacterial infections, usually
first
seen with subacute illness
EMPYEMA (contd)
DIAGNOSIS
- The possibility of empyema should be considered
during the initial evaluation of every patient with
bacterial pneumonia.
- Gross examined for pleural fluid: color, clarity and
odor.
- Analyzed for pleural fluid glucose, LDH, protein
level, pH, differential and total WBC counts.
- Bacterial culture for aerobic and anaerobic, Gram
stain, mycobacterial and fungal smear.
- The differential WBC: usually predominant
polymorphonuclear leukocyte.
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EMPYEMA (contd)
MANAGEMENT
1. Antibiotic selection
2. Pleural fluid management:
- Observation
- Tube thjoracostomy
- Intrapleural fibrinolytics
- Thoracoscopy
- Decortication
- Open drainage
HEMOTHORAX
DEFINITION: is the presence of the significant amount
of blood in the pleural space or when the pleural fluid
hematocrit is equal or more than 50% of the peripheral
blood hematocrit.
CAUSE OF HEMOTHORAX:
1.
Trauma: penetrating and non penetrating
2.
Iatrogenic
3.
Pulmonary embolism
4.
Rupture of an aortic aneurysm
5.
Malignant diseases
6.
Catamenial hemothorax
7.
Hemothorax complicating anticoagulant therapy
8.
Spontaneous hemothorax
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HEMOTHORAX (contd)
MANAGEMENT
1. Immediate chest tube insertion
2. Thoracotomy
3. VATS
COMPLICATION:
1. Empyema
2. Pleural effusion
3. Fibrothorax
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CHYLOTHORAX
Chylothorax is formed when the thoracic duct
is disrupted and chyle enters the pleural
space.
The pleural fluid is milky or at least turbid.
ETIOLOGY:
- Tumor: lymphoma
- Trauma: surgical trauma
- Idiopathic
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CHYLOTHORAX (contd)
DIAGNOSIS:
- Pleural fluid: milky
- Triglyceride level in pleural fluid > 110 ml/dl
TREATMENT:
- Chest tube insertion
- Intravenous hyperalimentation
- Pleurodesis
- Pleuroperitoneal shunt
- Ligation of the thoracic duct
MESOTHELIOMA
MALIGNANT MESOTHELIOMA: arise from the
mesothelial cells that line the pleural cavities.
Etiologic factors: exposure to asbestos.
Clinical manifestation: mostly between the ages of
40 – 70 years, insidious onset of chest pain,
usually non pleuritic or shortness of breath,
hacking cough, some irregular episode of low
grade fever, for several month.
Management: surgical treatment, chemotherapy
and radiotherapy.
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mesotelioma
mesotelioma
36
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